New York ACEP Website

Resident Forum Focus on Wellness

Wednesday, March 7, 2007

The New York Academy of Medicine

All those planning to attend must register in advance.

First Name: Last Name:

Credentials: MD DO FACEP Other Attending Physician

Residency Program: PGY (1, 2, 3, 4)

Mailing Address: Home Work

Department:

Institution:

Street:

City: State: Zip:

Daytime Telephone: Extension: Fax:

E-mail:

I would like to attend the small group workshop session.

(Limited to 50 registrants on a first-come-first-served basis).

Attending Physician $125 Payment Information

Payment Method: VISA MasterCard American Express

Check (Send to: New York ACEP, 1070 Sibley Tower, Rochester, NY 14604)

Card Number: Exp. Date: MM/YY

Cardholder Name: